Does Medicaid Cover CGM? State-by-State Guide

Imagine having diabetes managed without the prick of a finger to determine blood sugar or watching your blood sugar potentially swing dangerously high and low. That sounds amazing, right?

That is just what Continuous Glucose Monitoring or cgm devices do that allows large amount of happy diabetics to live life more healthfully, more balanced, and more active. The only downside? They’re expensive. If you are one of the millions of Americans who rely on Medicaid, you will surely be asking the question, “Does Medicaid cover Continuous Glucose Monitoring?” The answer? “Maybe”.

Sadly, Medi-Cal coverage of a CGM or Continuous Glucose Monitoring device is not universally defined. There is a huge amount of variability state to state and this can be quite confusing for people that need that need the assistance. In this article we summarize the state by state cgm medicaid coverage so you will know what to expect and how to get the coverage you need.

What is Continuous Glucose Monitoring (CGM)?

The clear distinction between the traditional finger-stick monitoring method, and the new CGM method, is that it reports concentration trends; they provide patients with cognitive and heightened awareness of their diabetes, providing patients with greater control over their diabetes management. CGMs, have the possibility to limit the lifetime risks of complications while managing chronic disease, such as diabetes.

Why Medicaid Coverage for CGM is Critical?

For so many individuals with diabetes, especially those who are on insulin, the benefit of a CGM is immeasurable. Unfortunately, many potential users may find CGM devices to be out of their price range if they do not have insurance coverage. This is where Medicaid comes in. Medicaid is a joint federal and state program that is often called upon to make CGMs available for individuals who live on lower incomes. Medicaid not only improves health outcomes but reduces the cost of healthcare in the long run.

Medicaid: A Quick Overview

Medicaid is a coverage health plan for low-income people before options from funding federal/state governments’ coverage plans are exhausted. Medicaid considers lowly paid persons, irrespective of whether or not such persons happen to be disabled or elderly: low-income children, low-income elderly, pregnant women with very low income, and persons with disabilities. However, since the federal government allows each state to determine its own eligibility guidelines for its unique Medicaid program, certain inconsistencies arise with regard to types and extent of coverage (for instance, would CGM medical equipment be covered?).

General Medicaid Coverage for CGM Devices

States may have different Medicaid benefits for CGMs. Among the elements influencing coverage are:

• Type of diabetes diagnosis: Type 1 vs. Type 2
• Insulin use: Need for insulin therapy
• Medical necessity: Documentation from a qualified healthcare provider
• Prior authorization: Approval processes prior to getting the device
• Specific CGM models: Some CGM coverage could be limited to specific brands 

Because of these factors, it is always best to check your state’s Medicaid policies or speak to a healthcare provider familiar with Medicaid policies in your state.

State-by-State Medicaid Coverage for CGM: In-Depth Breakdown

California

As of January 2022, California’s Medicaid program, Medi-Cal, officially expanded CGM coverage to individuals with Type 1 diabetes, previously specifically covering children. This policy change allows better and broader access to an essential tool for successful diabetes management.  

New York

On the other hand, New York Medicaid will pay for real-time CGMs for a member who has been diagnosed with Type 1 diabetes but only if the member meets certain qualifying criteria, such as being under the care of a qualified medical professional and performing multiple daily fingerstick tests. 

Texas

On February 1, 2024, the Texas Medicaid CGM/hypoglucemia coverage policy was revised to end the requirement for insulin use to allow broader access for people with diabetes who meet clinical criteria, thereby affecting access for anyone with Type 2 diabetes in particular. 

Florida

Florida does not have a stated Medicaid CGM coverage policy but there is a federal policy as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children less than 21 years old that could allow for the possibility of Continuous Glucose Monitors for children.

Illinois

In July 2024, Illinois passed legislation adding CGM access to Medicaid beneficiaries which brought the state line of policy into alignment with Medicare. The law eliminated previous barriers to access.

Pennsylvania

Pennsylvania’s Medicaid program provides coverage for CGMs for individuals with type 1 diabetes with stipulations for medical necessity and prior authorization. Additionally, the device and its related supplies are covered by Medicaid.

Ohio

Ohio Medicaid covers CGM for both Type 1 and Type 2 diabetes but requires meeting clinical criteria and prior approval.

Why Does Coverage Differ by State?

Medicaid CGM coverage variations arise from:

• Budget constraints: States have limited funding
• Policy priorities: States may have different areas of focus
• Population needs: Diabetes prevalence variances
• Legislative advocacy: CGM Coverage may vary and that depend on local advocacy.
• Medicaid expansion status: Benefits are more extensive for states that extended Medicaid under the Affordable Care Act.

How to Check Your State’s Medicaid CGM Coverage?

To assess your state’s coverage for CGM:

• Check your state Medicaid website: Review covered services and device policies.
• Call Medicaid call center: Get your benefits clarified, and eligibility details.
• Talk to healthcare provider: They can help you navigate Medicaid rules and understand the requirements.
• Ask diabetes advocacy groups: Check in with groups, such as the American Diabetes Association.

Requirements to Qualify for CGM Coverage Under Medicaid

Qualifying requirements are listed as follows:

• Diagnosis: A diagnosis of Type 1 or insulin-dependent Type 2 diabetes must be established.
• Insulin therapy: Must begin intensive insulin therapy.
• Medical justification: Must have some form of medical justification from a healthcare provider
• Prior authorization: Prior authorization from Medicaid or a managed care plan is required.
• Compliance: Must comply with all Medicaid application and re-enrollment procedures.

How to Apply for Medicaid CGM Coverage?

Family first, full steps to apply are:

• Confirm Medicaid eligibility: Confirm that you will be eligible based on your state of residency and state Medicaid.
• Consult your healthcare provider: Provide the needed prescription and documentation regarding your therapy; may be needed.
• Submit prior authorization requests: Follow the process established by your state.

Challenges Faced by Medicaid Beneficiaries

Common access barriers include:

• Delays: The time it takes to receive prior authorizations
• Limited options: Restrictions on brands or types of devices
• Costs: Potential co-pays or other fees
• Education: No training on the use of CGM
• Availability issues: Supply disruption of a device or sensor for a period of time

The Future of Medicaid CGM Coverage

As States are made aware of the benefits of continuous glucose monitoring, they are reconsidering their Medicaid policies to accommodate better access to service. This will continue as technology improves and advocates work to improve access.

Tips for Maximizing Medicaid CGM Benefits

• Partner with your healthcare providers: Ensure all forms are completed properly
• Stay Informed: Always be aware of the policies of your state that may change.
• Share with others: Learn from the experiences of others.
• Access case management services: Get help with managing the politics of the Medicaid system.

Conclusion

Access to Continuous Glucose Monitoring using Medicaid is a good way to participate in your diabetes management. Much like other state benefits, variation in coverage and access within states can be cumbersome to manage. It is your responsibility to understand access to benefits working with both your providers and advocacy groups. Do not be afraid to explore ways to make it easier to utilize CGM as part of your diabetes management plan!

Frequently Asked Questions (FAQs)

1. Does Medicaid cover CGM for all types of diabetes?

Availability of coverage for CGM devices differs by state. Some states cover CGMs for Type 1 and Type 2 diabetes, and other state programs can be very limited. 

2. Is prior authorization required for Medicaid CGM coverage?

Most states require prior authorization to show medical necessity prior to approving CGM devices and supplies through Medicaid, usually through their Medicaid and managed care programs.

3. Can Medicaid beneficiaries choose any CGM brand?

Not necessarily. Coverage may be specific to brands and/or models outlined by the State Medicaid and managed care plans. 

4. What documentation is needed to apply for CGM coverage through Medicaid?

Generally required items for applying for coverage are a doctor prescription, insulin dependent, history of glucose monitoring, and proof of medical necessity. 

5. How can I appeal if Medicaid denies CGM coverage?

You may submit a faceted appeal for Medicaid coverage of CGM by submitting additional medical documents or submit the denial to your patient advocate, medical professional, ect, to put forth your appeal.

Evelyn Brown